Provider Demographics
NPI:1558626689
Name:BLACK, ADAM HARRIS (NP)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:HARRIS
Last Name:BLACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7171 BUFFALO SPEEDWAY
Mailing Address - Street 2:APT 535
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1424
Mailing Address - Country:US
Mailing Address - Phone:205-960-6362
Mailing Address - Fax:
Practice Address - Street 1:7171 BUFFALO SPEEDWAY
Practice Address - Street 2:APT 535
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1424
Practice Address - Country:US
Practice Address - Phone:205-960-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX783129363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1558626689OtherTRICARE
TX303197302Medicaid
TX8NO301OtherBCBS
TXTXB161106Medicare PIN